Breast carcinoma associated with pregnancy and lactation

Noncontrast MRI with advanced diffusion weighted imaging for breast cancer detection in a lactating woman

Magnetic resonance imaging (MRI) is used for preoperative evaluation, high-risk screening, and other select indications for breast cancer. However, the interpretation of breast MR images in pregnant and lactating women is complicated by physiologic changes of the breast that may result in marked background enhancement. Breast MRI with contrast administration is contraindicated in pregnancy. Restriction spectrum imaging (RSI) is an advanced diffusion-weighted (DW)-MRI method that theoretically reflects signal from cells with high nuclear-to-cytoplasm ratio without gadolinium-based contrast. This report describes a case in which RSI notably increased tumor conspicuity in a lactating woman, compared to contrast-enhanced (CE)-MRI and conventional DW-MRI.

Surgery for Pregnancy-Associated Breast Cancer

Surgery in the form of both mastectomy and breast conservation is the main step in the treatment of breast cancer. Numerous studies have shown an equivalent long-term survival for breast conserving surgery (BCS) and mastectomy . Patients desire and tumor characteristics, especially size and multicentricity, are the key factors that affect the decision between these two types of surgery . Patients with any contraindication for radiotherapy or previous history of radiation to the breast field are not suitable for BCS . There are few absolute contraindications for BCS , and early pregnancy is listed among them; mastectomy is preferred in the first trimester of pregnancy to avoid the impact of delaying radiation therapy on outcome of the cancer.

Two cases of breast carcinoma during pregnancy and review of the literature

Pregnancy-associated breast cancer is the most common solid tumor in pregnancy after cervical carcinoma but still has a low incidence. It has been associated with a poor prognosis; though based on a limited number of retrospective case-control studies, some authors have reported no differences from that of non-pregnant patients. There is no consensus about the treatment; it requires an interdisciplinary approach and it is necessary to balance between the benefit for the mother and risk for the fetus. Each case requires an individual decision taking into account the stage of disease, patient preferences and gestational age. Above chemotherapy, it is only recommended after the first trimester of pregnancy and anthracyclin-based schemes have the higher evidence, but taxanes are also considered as an alternative in patients who do not respond to anthracyclines or its use is contraindicated. For the time being, there is a lack of data, and clinical decisions are based on small retrospective cohorts, case-control studies and case reports. We report two cases of patients being diagnosed with breast cancer while being pregnant and treated with surgery and chemotherapy, including anthracyclines, during the second and third trimester of pregnancy. In both reported cases, childbirth was induced before the 37th week of gestation and only one presented low birth weight with no more complications. The echocardiogram monitorization showed normal cardiac function in mothers and fetus.

Risk factors for pregnancy-associated breast cancer: a report from the Nigerian Breast Cancer Study

PURPOSE

Little is known about risk factors for pregnancy-associated breast cancer (PABC), diagnosed during pregnancy or postpartum.

METHODS

We enrolled 1715 premenopausal women from the Nigerian Breast Cancer Study from 1998 to 2011. Based on recency of last pregnancy from diagnosis, breast cancer cases were categorized as (1) PABC diagnosed 2 years or longer postpartum, (2) PABC diagnosed 3 to 5 years postpartum, or (3) non-PABC diagnosed more than 5 years postpartum. Controls were matched to cases on recency of last pregnancy. Multiple logistic regressions were performed comparing cases and controls within each group.

RESULTS

Of the 718 cases, 152 (21.2%) had PABC 2 or more years postpartum, and 145 (20.2%) 3 to 5 years postpartum. Although not statistically significant, women with higher parity tend to have an elevated risk of PABC but reduced risk of non-PABC (p for heterogeneity = 0.097). Family history of breast cancer might be a strong predictor particularly for PABC 2 or more years postpartum (odds ratio, 3.28; 95% confidence interval, 1.05-10.3). Compared with non-PABC cases, PABC 2 or more years postpartum cases were more likely to carry BRCA1/2 mutations (P = .03).

CONCLUSIONS

Parity may have different roles in the development of PABC versus other premenopausal breast cancer in Nigerian women. Prospective mothers with multiple births and a family history of breast cancer may have an elevated risk of breast cancer during their immediate postpartum period.

Pregnancy associated breast cancer and pregnancy after breast cancer treatment

Breast cancer is one of the most common cancers diagnosed during pregnancy and its frequency is increasing as more women postpone their pregnancies to their thirties and forties. Breast cancer diagnosis during pregnancy and lactation is difficult and complex both for the patient and doctors. Delay in diagnosis is frequent and treatment modalities are difficult to accept for the pregnant women. The common treatment approach is surgery after diagnosis, chemotherapy after the first trimester and radiotherapy after delivery. Even though early stage breast cancers have similar prognosis, advanced stage breast cancers diagnosed during pregnancy and lactation have poorer prognosis than similar stage breast cancers diagnosed in non-pregnant women. Women who desire to become pregnant after treatment of breast cancer will have many conflicts. Although the most common concern is recurrence of breast cancer due to pregnancy, the studies conducted showed that pregnancy has no negative effect on breast cancer prognosis. In this review we search for the frequency of breast cancer during pregnancy, the histopathological findings, risk factor, diagnostic and treatment modalities. We reviewed the literature for evidence based findings to help consult the patients on the outcome of breast cancer diagnosed during pregnancy and lactation, and also inform the patients who desire to become pregnant after breast cancer according to current evidences.

Breast cancer in pregnancy

Breast cancer in pregnancy is rare with an incidence of 1:3,000 to 1:10,000 and is the second most common after cervical cancer. The outlook for such patients is less favourable than that of non- pregnant women probably because the stage of the disease is more advanced when it is discovered and also due to delay in therapy. The need for prompt treatment presents a clinical dilemma of considerable magnitude as there is always a conflict between optimal maternal therapy and the resultant risks imposed on fetal well-being. In the absence of a standardised protocol for management, this review focuses on the issues of diagnosis and treatment of breast cancer in pregnancy. Relevant current literature using Medline search strategy was examined.

Diagnosis and therapy of gestational breast cancer: a review

PURPOSE

In spite of the general consensus on the issue, to point to major dilemmas which appear in this matter of multidisciplinary interest, and to review current concepts on how to achieve optimal diagnostic and therapeutic outcome.

RESULTS

Recent literature data show that the rate of gestational breast cancer, according to most protocols, range from 0.2% to 3.8%. By definition, the clinical manifestation of this type of carcinoma is expected to occur during pregnancy or within one year after delivery. The mode of treatment and prognosis is identical to those of women with breast carcinoma beyond pregnancy, except for radiotherapy that is not indicated during pregnancy and selective use of cytostatics in polychemotherapy during the first trimester. The only exceptions to this practice are women with any advanced stage of the disease due to delayed diagnosis. Results of large studies indicate that the therapy for breast cancer has no adversarial effect on the prognosis of subsequent pregnancy.

CONCLUSION

The evaluation and management of women with gestational breast cancer requires a multidisciplinary approach. A chemotherapeutic regimen should be individualised to a maximum reduction of risk, if applied in the second and third trimester. Surgical therapy may include mastectomy and sparing operative procedures. Sentinel node biopsy should be considered in node negative patients. Radiotherapy should be postponed to the postpartum period.

[Breast carcinoma during pregnancy]

Pregnancy associated breast cancer includes cancers concurrent with pregnancy and those diagnosed up to 1 year after delivery. The incidence of breast carcinoma in pregnancy is estimated to be approximately 1 in 3000 pregnancies. Due to the difficulties of clinical breast examination, diagnosis is frequently delayed and made when the cancer stage has progressed. Consequently, prognosis is usually poor. Treatment options are limited by concern about harming the fetus and depend on gestational age. We present the case of a 34-year-old woman who was diagnosed with cancer of the right breast in the 28th week of gestation. The patient underwent modified radical mastectomy. This association is uncommon but is not exceptional. Knowledge of cases such as that reported herein will allow early diagnosis and improve the prognosis of these patients.

Pregnancy-Associated Breast Cancer: A Literature Review

Breast cancer is one of the most commonly diagnosed cancers of pregnancy. The diagnostic and therapeutic implications in this population are special. These women typically present with more advanced disease that carries a poorer prognosis. This article highlights patient care in this population, where aggressive care must be modified to ensure fetal protection.

Palpable masses in breast during lactation

OBJECTIVES

Diagnosis of breast cancer is more difficult in pregnant and lactating women. In the present study, the value of different radiological methods has been evaluated.

MATERIAL AND METHODS

Twenty-seven patients with palpable breast masses during the lactation period were evaluated. All masses were investigated in the clinical course as well as in ultrasound. If ultrasound demonstrated a suspicious lesion a mammogram was done. If clinical course, ultrasound, and mammography could not rule out breast cancer, MR mammography was done.

RESULTS

Eighteen ultrasound-guided biopsies were done, revealing three cysts, seven hyperplasias/mastopathia, three cases of papilloma, and two carcinomas. The 18 mammograms were classified as BI-RADS 1 and 2 in nine cases, as BI-RADS 3 in seven case, as BI-RADS 4 in one cases, and as BI-RADS 5 in also one case. MR mammography was done in 9 cases revealing three BI-RADS 4 categories and one BI-RADS 5 category, all of them showed a malignant histology.

CONCLUSIONS

The density of the lactating breast compromises breast cancer diagnosis. Ultrasound should be the method of choice. If possible mammography and MR mammography should be done after lactating period.

Pregnancy-associated breast cancer -- special features in diagnosis and treatment

For obvious psychological reasons it is difficult to associate pregnancy -- a life-giving period of our existence -- with life-threatening malignancies. Symptoms pointing to malignancy are often ignored by both patients and physicians, and this, together with the greater difficulty of diagnostic imaging, probably results in the proven delay in the detection of breast cancers during pregnancy. The diagnosis and treatment of breast cancer are becoming more and more important, as the fulfillment of the desire to have children is increasingly postponed until a later age associated with a higher risk of carcinoma, and improved cure rates of solid tumors no longer exclude subsequent pregnancies. The following article summarizes the special features of the diagnosis and primary therapy of pregnancy-associated breast cancer with particular consideration of cytostatic therapy.

Enhanced expression of leptin and leptin receptor (OB-R) in human breast cancer

PURPOSE

To evaluate leptin and leptin receptor (OB-R) expression in human breast cancer and determine whether it could be effective for the prevention and treatment of breast cancer.

EXPERIMENTAL DESIGN

Immunohistochemical staining using specific antibodies was used to evaluate the protein expression of leptin and OB-R in 76 invasive ductal carcinomas and 32 samples of corresponding normal mammary gland, and the relationship between the expression of OB-R and leptin and clinicopathological features was analyzed.

RESULTS

Normal mammary epithelial cells did not express a significant level of Ob-R, whereas carcinoma cells showed positive staining for OB-R in 63 (83%) cases. Both normal epithelial cells and carcinoma cells expressed a significant level of leptin. However, overexpression of leptin, as determined by staining intensity, was observed in 70 cancers (92%) but in no normal epithelium. The expression of OB-R showed a significant correlation with the level of leptin expression. Interestingly, distant metastasis was detected in 21 (34%) of 61 OB-R-positive tumors with leptin overexpression, but in none of the 15 tumors that lacked OB-R expression or leptin overexpression (P < 0.05). Consequently, patients with the former tumors showed significantly lower survival than those with the latter.

CONCLUSIONS

Leptin may have a promoting effect on the carcinogenesis and metastasis of breast cancer, possibly in an autocrine manner. Functional inhibition of leptin may be effective for the prevention and treatment of breast cancer.

Bovine mammary progenitor cells: current concepts and future directions

Although cell number is positively correlated with milk production, much remains to be learned about the bovine mammary stem cell and progenitor cells. Bovine mammary development is driven by many of the same classic mammogenic hormones studied in murine models, yet histologic features of bovine mammary development differ from that of rodent models. Most notably, terminal end buds, as they have been described for murine models, do not exist in the bovine mammary gland. However, among the most important common features of mammary development in disparate species is the involvement of histologically distinct, lightly staining epithelial cells as putative stem and progenitor cells. Although stem cell research has often focused on mammary development, mammary stem cells seemingly provide the basis for mammary growth and cell turnover in the mature animal. These cells provide an obvious focus for research aimed at increasing the efficiency of milk production. This review addresses recent findings concerning the histology and molecular physiology of putative bovine mammary stem and progenitor cell populations, areas where more study is critically needed, and areas where studies of bovine mammary physiology may present a unique opportunity to better understand mammary physiology in many species.

Pregnancy and breast cancer: a population-based study

The incidence of pregnancy-associated breast cancer, i.e. during pregnancy and lactation, and of pregnancy subsequent to a breast-cancer diagnosis will increase as more women choose childbearing at a later age. Few larger series are published on pregnancy-associated breast cancer. In a population-based study, we evaluated the outcome and prognostic factors in 173 breast-cancer patients. One hundred and twenty-two patients had pregnancy-associated breast cancer (20 coincident with pregnancy and 102 during lactation) and 51 patients had pregnancy subsequent to breast cancer. The median follow-up time was 151 months. Histopathological parameters and immunoreactivity for oestrogen and progesterone receptors c-erbB-2 and c-erbB-4 were studied. All three groups had tumours with high histological grade, low frequency of hormone receptors and high expression of c-erbB-2. The pregnancy and lactation groups were near identical with regard to all histopathological parameters and outcome. In the two pregnancy-associated breast-cancer groups, tumours were significantly larger, with more extensive lymph-node involvement. For node-negative tumours the respective 5- and 10-year survival rates were 62% and 50% in the pregnancy group and 60% and 50% in the lactation group. For node-positive tumours, respective 5- and 10-year survival rates were 50% and 34% in the pregnancy group and 50% and 33% in the lactation group. In the subsequent group, overall survival was high in both node-negative and -positive groups, with 5- and 10-year survival rates of 80% and 73% and 86% and 76%, respectively. Tumour size, lymph-node status, histological grade, progesterone receptor, oestrogen receptor and c-erbB-2 were significant prognostic factors in the pregnancy-associated breast-cancer patients.

Management of breast cancer diagnosed during pregnancy

Breast cancer during pregnancy is generally defined as cancer occurring during pregnancy or within 1 year of delivery, although treatment options are the most complicated when the disease is diagnosed during gestation. The challenges of treatment during gestation are discussed in this article. In general, a pregnant woman with breast cancer should be treated similarly to the nonpregnant patient, with specific recommendations tailored to gestational age at diagnosis, stage of the tumor, and the personal preferences of the patient. Despite the increasing literature focusing on treatment decisions, there are little prospective data regarding treatment or long-term outcome information to provide toxicity data that can be used to advise patients and guide decisions. Most of the retrospective and anecdotal data are based on the possibility of fetal loss or demise with specific treatment or treatment administered at specific times during pregnancy. Therefore, it is impossible to accurately quantify risks to the fetus or the mother, and decisions should be made after careful discussion between the patient, her family, and the medical team. The physician must have a clear understanding of the pharmacology and teratogenic potential of individual agents, thus limiting risks.

Multidisciplinary management of breast cancer concurrent with pregnancy

The management of PABC is very difficult. The incidence of PABC is low, but may be increasing because of the number of women who are becoming pregnant at a later age. More investigation is needed to understand whether the biology of PABC is different from that of breast cancer in nonpregnant women. One exciting area of further research is the potential relationship between mutations in known breast cancer susceptibility genes and breast cancer development during pregnancy. Diagnosis or PABC remains challenging because of the anatomic and physiologic changes that occur in the breast during pregnancy. Understanding the generic influences on PABC may help physicians in diagnosing this disease earlier, and understanding the tumor-receptor characteristics of PABC can help physicians deliver effective treatment. The various modalities available for treatment of PABC and their risks and benefits must be discussed openly with patients and their families. Abortion is not usually recommended. Modified radical mastectomy is the recommended treatment for PABC diagnosed during the first trimester. Neoadjuvant or adjuvant chemotherapy can be given with minimal risks to the fetus during the second or third trimester. Radiation therapy is contraindicated during pregnancy because of the potential for injury to the fetus. Breast conservation therapy, with radiation treatments given after delivery or after neoadjuvant chemotherapy, is an option for women with PABC diagnosed late in pregnancy. Once the appropriate treatment modality is chosen, its implementation must not be delayed because of the pregnancy. Most of the literature shows that women with PABC have the same survival stage for stage as nonpregnant women with breast cancer. But some studies suggest that the prognosis is worse for patients who present with advanced-stage PABC. Finally, recurrence and survival in most patients previously treated for breast cancer do not appear to be adversely affected by subsequent pregnancy. Above all, the patient with breast cancer diagnosed during pregnancy is best served by early and continued involvement of a multidisciplinary cancer treatment team.